Chapter 8 - Intrapartal Period: Assessments and Interventions

Question 21. A group of pregnant women in the third trimester of pregnancy are attending a childbirth education class. When teaching about the differences between true labor and false labor, what would the nurse note about false labor? 1. The cervix does not dilate. 2. The contractions get stronger. 3. The cervix becomes thinner. 4. The contractions get closer together.

Ans:1 Option 1: There is no cervical change in false labor. Option 2: The contractions will not increase in intensity in false labor. Option 3: The cervix will not efface in false labor. Option 4: The contractions will not become more frequent in false labor.

Question 27. A client calls the nurses station to report that she thinks her water has broken. The nurse obtains supplies to assess the client. which would the nurse explain to the client prior to performing the vaginal exam? 1. "The vaginal exam allows for the assessment of the fetal heart rate." 2. "Laboring women often urinate and think it was the water breaking; let me check." 3. "Your risk of infection has gone down now that the amniotic fluid has ruptured." 4. "The lab test confirms that your amniotic fluid has ruptured."

Ans : 4 Option 1: The vaginal exam would allow for assessment of a prolapsed cord, but not the fetal heart rate. Option 2: While women can urinate, this response is not therapeutic. Option 3: The risk of infection increases when the amniotic fluid ruptures. Option 4: An AmniSure test is 99% accurate in verifying if the membranes have ruptured.

Question 53. Per provider order, the nurse is preparing to administer oxytocin to a client who is in the third stage of labor. The order is for 20 units of oxytocin in 1,000 milliliters of lactated ringers, and the client is to receive a 10-unit bolus over one hour. What will the IV pump be programmed to for the administration of this bolus dose? Record your answer in ml/hr.

Ans: 500

Question 17. A woman has been using nonpharmacological pain relief methods during labor, but now requests nalbuphine (Nubain). which finding would cause the nurse to hold the medication dose? 1. Blood pressure 138/76 2. Moderate variability on the fetal heart tracing 3. Client rating the pain 8/10 4. A history of prescription narcotic pain medication abuse

Answer: 4 Option 1: Nalbuphine is an opioid agonist-antagonist. Like narcotic pain medication, it should not be given to someone whose blood pressure is low. This blood pressure would be acceptable. Option 2: Nalbuphine can cause a transient decrease in variability. Moderate variability is considered a normal finding, and this infant could tolerate the brief effects of the medication. Caution would be warranted with an infant who has minimal variability. Option 3: The client's pain scale is subjective and based on their perception. The nurse should not withhold pain medication because they do not agree with what the client is rating the pain. Option 4: Due to its opioid antagonist properties, nalbuphine could precipitate sudden withdrawal symptoms in a person with a history of drug abuse.

Question 8. During labor and delivery, the fetus passes through the birth canal and must make several movements to allow for successful delivery. Place the following cardinal movements for birth into the correct order. 1. Descent 2. Expulsion 3. Extension 4. Flexion 5. External rotation 6. Engagement 7. Internal rotation

Answer: 6,1,4,7,3,5,2

Question 19. During labor, nurses provide continuous support to clients. which are the outcomes seen from this support? Select all that apply. 1. Decrease in operative births 2. Increase in likelihood of breastfeeding 3. Decrease in childbirth satisfaction 4. Decrease in pharmacologic pain management 5. Increase in labor length

Answer: 1,2,4 Option 1: Labor support sees a decrease in cesarean births and operative vaginal deliveries. Option 2: Support can increase the number of mothers who breastfeed. Option 3: Mothers who have support during labor are more satisfied with the experience. Option 4: Continuous labor support allows for use of many nonpharmacologic methods and can decrease the use of pharmacologic methods. Option 5: Support during labor can decrease the length of labor.

Question 11. The nurse is admitting a 16-year-old client for induction. She expresses fear about the pain of labor and delivery. which is the best response by the nurse? 1. "Since you are under 18, your mom will decide what type of pain management is best for you." 2. "You should get an epidural. You won't feel any labor, but pushing may be more difficult." 3. "There are many options for pharmacological and non pharmacological pain relief. I'll discuss the pros and cons with you." 4. "Childbirth classes are a great way to learn about pain relief options. Did you attend any?"

Answer: 3 Option 1: Adolescents have a very different view of labor and birth as they struggle with self-identity and self-esteem. The nurse should include the client in decision-making as much as possible. Option 2: Epidurals may be good pain relief choice for some, but the nurse failed to inform the client of all options, thereby taking away her choice. Also, epidurals may not fully remove the pain of labor. Option 3: This response by the nurse respects the client's right to be informed and make decisions. The nurse should provide anticipatory guidance on various options, as adolescents have fewer coping mechanisms when dealing with pain. Option 4: This response fails to address the client's concerns. It is also too late to discuss childbirth classes as the client is being admitted for induction.

Question 13. Immediately following the delivery of the placenta, the nurse prepares to administer IV oxytocin. The client states, "What is this medication for?" which is the nurse's best response? 1. "To augment labor contractions" 2. "To improve the let-down reflex for your breastmilk." 3. "To prevent hemorrhage after delivery." 4. "To prevent uterine cramping and pain following delivery."

Answer: 3 Option 1: Oxytocin is used to augment contractions during the first stage of labor. This question is asking specifically about its use in third stage labor. Option 2: Endogenous oxytocin release is triggered by nipple stimulation. It causes the let-down reflex in breastfeeding women. However, exogenous oxytocin is not given for this reason. Option 3: The World Health Organization (WHO) and Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) recommend oxytocin use during the third stage of labor in all deliveries to prevent postpartum hemorrhage. Option 4: Uterine atony is the leading cause of postpartum hemorrhage (PPH). Oxytocin is a uterotonic that causes uterine cramping and is given to prevent PPH.

Question 16. Based on the image, which degree perineal laceration did this client experience? 1. First degree 2. Second degree 3. Third degree 4. Fourth degree

Answer: 4 Option 1: A first-degree laceration involves the perineal skin and vaginal mucous membrane. Option 2: A second-degree laceration involves skin, mucous membrane, and fascia of the perineal body. Option 3: A third-degree laceration involves skin, mucous membrane, and muscle of the perineal body and extends to the rectal sphincter. Option 4: A fourth-degree laceration extends into the rectal mucosa and exposes the lumen of the rectum.

Question 7. The nurse is assessing a client who has just delivered a baby and calculates the initial blood loss from delivery to be 338 g. Over the next couple of assessments, the nurse changes the chux pads under the client due to bleeding. The chux pads weigh 128 and 242 g. The nurse knows that the client has had an estimated blood loss of how many milliliters? Report your answer in mL. Enter only the numerical value.

Answer: 708

Question 43. A full-term infant girl was born one minute ago. She is centrally pink with blue hands, her heart rate is noted at 148bpm, her arms and legs are flexed closely to her body, and she is crying vigorously. Using the table, calculate the Apgar score. 1.- 6 2.- 7 3.- 8 4.- 9

Answer: Option 4.-9 Option 4: Based on the question description, the following points would be assigned:Respiratory effort = 2 Heart Rate = 2 Muscle tone = 2 Reflex activity = 2 Color = 1 Total = 9

The nurse is caring for a term gestation client in active labor when her membranes rupture spontaneously. Prioritize the following nursing interventions. 1.Document the assessment findings along with the time of rupture. 2. Assess the color, odor, and amount of fluid. 3. Assess the fetal heart rate. 4. Update the physician on the spontaneous rupture of membranes and labor progress.

Answers: 3,2,1,4

Question 49. While caring for a pregnant client, which can the nurse provide to decrease fear and anxiety throughout labor and delivery? 1. Ambulation 2. Confidence 3. Pain medication 4. Labor support

Ans; 4 Option 1: Ambulation may or may not be comforting to the client. Option 2: Confidence will increase the nurse's ability to provide labor support. Option 3: While increasing comfort through support could be to use pain medication, it is too narrow of a focus. Option 4: Research and theories have identified that support for emotions and comfort measures can reduce both fear and anxiety.

Question 30. The nurse is assisting a client who is in early labor and experiencing intense back pain with nonpharmacologic pain management. Which technique can the nurse implement for this client? 1. Counter pressure over the sacral area 2. Effleurage over the abdomen 3. Use of an ice pack over the forehead 4. Playing music that is upbeat

Ans: 1 Option 1: For pain occurring when the fetus is in the posterior position, the nurse or support person can offer some relief by providing counter-pressure with the heel of the hand. Option 2: This technique is used to lightly stroke the abdomen during contractions, but it is not specific to back labor. Option 3: While this may help if the mother is overheating, it is not specific to assisting with back labor. Option 4: Music can help with mental stimulation, but it is not specific to assisting with back labor.

Question 32. The nurse is instructing a woman and her partner on non-pharmacological pain relief interventions such as effleurage and using heat/cold. The client asks how these techniques work to manage pain. Which is the best statement by the nurse? 1. "Only a certain number of sensations can travel to the brain at once. We replace pain signals with pleasure signals to reduce discomfort." 2. "Massage and heat reduce blood flow to tissues, and temporarily numb the nerve fibers." 3. "The placebo effect makes the client believe their pain is less, even though there is no physiologic benefit of the techniques." 4. "The effects are only useful in latent phase labor. As active labor starts, she will likely need opioid pain medication."

Ans: 1 Option 1: Gate Control Theory of Pain states that because of the limited number of sensations that can travel along these pathways at any given time, an alternate activity can replace travel of the pain sensation, thus closing the gate control at the spinal cord and reducing pain impulses traveling to the brain. Option 2: Massage and heat increase circulation to tissues, thereby providing better oxygenation and reducing tissue hypoxia. Option 3: There are physiologic benefits to massage, use of heat/cold, and breathing exercises, such as increased circulation and oxygenation of tissues. It is not purely a placebo effect. Option 4: If used effectively, non-pharmacological pain management can be adequate throughout both latent and active phases, especially when combined with continuous labor support.

Question 38. The nurse is caring for a laboring client who is waiting for the anesthesiologist to come administer the epidural. Which does the nurse anticipate that the obstetrician will order for this client to prevent a common adverse reaction following the epidural placement? 1. IV fluid bolus 2. Left-tilt position 3. Check vitals every 5 minutes 4. Assist client to bathroom

Ans: 1 Option 1: Hypotension occurs in 40% of epidurals, and it is decreased by the infusion of a fluid bolus. Option 2: Left-tilt position offers only a temporary solution to prevention of hypotension. Option 3: This is important, but it does not offer a preventative measure. Option 4: This is important, but it does not assist with prevention of hypotension.

Question 26. The nurse is assisting a pregnant client, who is placing the baby up for adoption, with the development of a birth plan. which questions would the nurse consider when planning the birth plan? Select all that apply. 1. Will the client spend some time alone with the infant? 2. How involved will the adoptive parents be in the birth? 3. Does the client plan to leave the hospital immediately after delivery? 4. Where are the closest support groups for birth parents? 5. Who will be present at the hospital to support the client?

Ans: 1,2,4,5 Option 1: It is common for birth mothers to choose to spend time with the infant prior to relinquishment. Option 2: The birth mother can decide at what time the adoptive parents will be involved. Option 3: Following delivery, the client should stay in the hospital for at least 24 hours to ensure that recovery from birth is occurring well. Option 4: Support groups offer guidance during the difficult time that birth parents go through following relinquishment. Option 5: It is important that the client have a support group beyond the adoptive parents, as this offers support for her during a challenging time.

Question 42. The nurse is preparing the client for epidural anesthesia. Which assessments or interventions would the nurse perform prior to administration? Select all that apply. 1. Check the platelet level. 2. Perform the procedure time-out. 3. Determine that the client is dilated to at least 5cm. 4. Ensure the consent has been signed. 5. Administer IV fluid bolus of normal saline or lactated ringers.

Ans: 1,2,4,5 Option 1: Lab values, especially for bleeding or clotting, should be checked for abnormalities. Option 2: Time-out verification procedures ensure client safety by identifying the client, the procedure to be done, any allergies or medical conditions, and the fire score. Option 3: Research does not support mandating that the woman be a specific dilation prior to receiving an epidural. It is based on client preference. Option 4: The client must be informed of the risks and benefits of the procedure, as well as any alternatives by the anesthesiologist, before signing the consent. The consent must be signed to perform the invasive procedure. Option 5: Administration of an IV fluid bolus is important in preventing post-epidural hypotension.

Question 29. The nurse is assessing the APGAR score on an infant at 1 minute of age. The infant has a lusty and vigorous cry with active motion of the extremities. The heart rate is 98 beats per minute. The respirations are 55 per minute, and the oxygen saturation is 98%. Acrocyanosis is noted on the hands and feet. which does the nurse record for the APGAR score? 1. APGAR 10 2. APGAR 8 3. APGAR 9 4. APGAR 7

Ans: 2 Option 1: The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is less than 10. Option 2: The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is 8. Option 3: The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is less than 9. Option 4: The infant will get 2 points for respiratory effort due to the good cry, 1 point for the heart rate below 100bpm, 2 points for active motion in muscle tone, 2 points for the vigorous cry in reflex activity, and 1 point for the acrocyanosis. The total is more than 7.

Question 37. The grandmother of a newly-delivered infant was in the room for the delivery. The newborn is placed skin-to-skin with the mother and covered with a warm blanket while waiting for the placenta to deliver. The grandmother expresses concern that the newborn is too cold with no clothes on. Which is the best response by the nurse? 1. "I will check the temperature when I have time." 2. "Skin-to-skin contact helps newborns to regulate temperature." 3. "Please just stand out of the way of the provider." 4. "The warm blanket will stop all cold air from reaching the baby."

Ans: 2 Option 1: This answer does not demonstrate therapeutic communication. Option 2: Skin-to-skin contact eases the transition for newborns, helping with thermoregulation and breastfeeding initiation. Option 3: This answer choice does not address the grandmother's concern. Option 4: While the blanket helps with some, it is not possible to prevent all cold air from reaching the infant.

Question 33. The nurse is caring for a client who has been dilated to 10 cm for about one hour. When assessing the client, her mother asks why the nurse has not started telling her daughter to push. Which is the appropriate response from the nurse? 1. "Times are different now, we do not make women push if they do not want to." 2. "The baby does better at birth if the mother waits to push once she feels the urge." 3. "It is best to start pushing one hour after reaching full dilation. It will start soon." 4. "The provider is not here yet, so pushing must be delayed."

Ans: 2 Option 1: When communicating with clients and families, therapeutic communication must always be followed. Option 2: Evidence demonstrates that there is improved fetal oxygenation, optimal maternal energy, and improved APGAR scores from laboring down or physiologic second-stage labor care. Option 3: Historically, pushing occurred immediately once full dilation was reached. Now, it is considered best to wait until the mother feels the urge to push. Option 4: The second stage of labor can last a couple hours. It is not uncommon for the provider to come closer to the impending delivery.

Question 50. Upon admission, the nurse instructed a 39-week gestation client to lie on her back in bed for assessment and placement of the fetal monitor. After going through the medical history, the nurse assesses the client's blood pressure at 76/42. Which is the appropriate intervention? 1. Retake the blood pressure with a manual cuff. 2. Move the client onto her left side. 3. Call the provider to obtain an order for IV fluids. 4. Continue to monitor blood pressure every 30 minutes.

Ans: 2 Option 1: With the blood pressure this low, the fetus is at risk due to decreased placental perfusion. Prompt intervention to bring the blood pressure up is important. Option 2: When lying flat on the back, the client may have supine hypotension due to compression of the aorta and ascending vena cava. The client should be placed into a side-lying position. Option 3: IV fluids may help the blood pressure, but this would not be the priority intervention. Option 4: The blood pressure is too low, and intervention is warranted immediately.

Question 51. A client is admitted to the labor and delivery unit in active labor. There has been no prenatal care for the current pregnancy, and the on-call provider estimates the pregnancy to be around 35 weeks' gestation. Which medication will the nurse anticipate being ordered for on this client? 1. Oxytocin 2. Penicillin 3. Magnesium sulfate 4. Metoclopramide

Ans: 2 Option 1: Oxytocin is given to stimulate uterine contractions. The woman is in active labor, so this would not be indicated. Option 2: With no prenatal care, the Group B strep status is unknown. Penicillin is the drug of choice to use during labor to prevent GBS infection in the neonate. Option 3: Magnesium is given to women with preeclampsia, so is not indicated at this time. Option 4: Metoclopramide is given for nausea and vomiting. There is not known history of this medication, so this is not indicated.

Question 36. The nurse is assessing a laboring client. Which signs and symptoms does the nurse recognize that indicate movement into the transition phase of labor? Select all that apply. 1. Contractions every 3 to 4 minutes 2. Contractions lasting 60 to 90 seconds 3. Cervix dilated to 8 cm 4. Noted trembling of client 5. Increase in client anxiety

Ans: 2,3,4,5 Option 1: During the transition phase of labor, contractions occur every 1 to 2 minutes. Option 2: Contractions are 60 to 90 seconds long in the transition phase. Option 3: Cervical dilation goes from 8 to 10 cm during the transition phase. Option 4: Clients will often feel trembling during the transition phase. Option 5: Clients will often experience increased anxiety in the transition phase.

Question 35. The charge nurse is observing a new nurse on the labor and delivery floor caring for a client in active labor and recognizes the need for additional training. Which care provided by the new nurse demonstrates a need for further orientation? Select all that apply. 1. The new nurse encourages client to use the restroom every hour. 2. The new nurse recommends client stay in bed and rests until it is time to push. 3. The new nurse explains all procedures to the client throughout the shift. 4. The new nurse suggests that all family members leave the room. 5. The new nurse assists client with breathing techniques to help with relaxation.

Ans: 2,4 Option 1: Frequent emptying of the bowels and bladder is beneficial to labor progress. Option 2: Active labor is enhanced by frequent position changes, and upright positions are best for fetal descent. Option 3: Education can help to reduce maternal fear and anxiety. Option 4: Support from family members can be beneficial to labor progress. Option 5: Supporting client with comfort measures will allow for a better labor experience.

Question 28. Following the assessment of a newly-admitted laboring client, the nurse documents the client to be 4cm, 30%, and -3 with contractions every 4 to 5 minutes and lasting 45 seconds. which phase of labor does the nurse assess the client to be in? 1. Second stage 2. Third stage 3. Latent phase 4. Transition phase

Ans: 3 Option 1: The second stage of labor occurs once the client has reached 10cm. Option 2: The third stage of labor occurs once the client has delivered the infant. Option 3: Labor has not yet progressed to more regular contractions indicative of the active phase of labor. Option 4: The labor has not yet progressed to the active phase, and transition follows this part.

Question 31. The nurse instructs the client on second stage positioning and pushing techniques. The nurse recognizes that the client understands the teaching when the client states: 1. "Holding my breath helps increase pressure and push the baby out." 2. "Having my legs in stirrups reduces the risk that I will tear." 3. "Pushing on my side can increase blood flow to the baby." 4. "I should begin pushing as soon as I am completely dilated.

Ans: 3 Option 1: Using the Valsalva maneuver is discouraged. It decreases the amount of oxygen reaching the fetus. Option 2: The lithotomy position is frequently used, but it is not ideal for giving birth. A side-lying position would reduce the risk of perineal tears. The lithotomy position makes it easiest for the provider to control delivery. Option 3: Side-lying (either left or right) decreases vena cava compression and increases blood flow to the uterus and placenta. This position is especially helpful if the fetus is not tolerating pushing well. Option 4: Delaying pushing and waiting for the spontaneous urge to bear down is known as laboring down. Laboring down can decrease maternal exhaustion, reduce the chance of needing forceps or vacuum, and shorten second stage labor.

Question 40. The nurse is caring for a client who is in the second stage of labor. The client's partner appears uncomfortable and unsure of what to do during the second stage of labor, while the client is highly emotional and exhausted. Which is the appropriate nursing response to the client's partner at this time? 1. "Did you not take childbirth classes? 2. "Do you want me to go get you a glass of water?" 3. "Would you like me to show you how to assist your partner?" 4. "Did you read your partner's birth plan?"

Ans: 3 Option 1: While childbirth classes do offer a learning opportunity, this question does not apply at this time. Option 2: During the second stage of labor, a nurse should never leave the room while a client is pushing. Option 3: Partners often feel emotional during the labor process, and they may forget what was learned in childbirth classes. Supporting them to support their partner is beneficial to the labor process. Option 4: While the birth plan may have considered the role of the partner, this response is not therapeutic.

Question 52. The nursery nurse is caring for a neonate who requires resuscitation. Place the resuscitation interventions given in the sequence in which the nurse will administer them. 1. Provide positive pressure ventilation by CPAP. 2. Administer epinephrine to the neonate. 3. Reposition mouth and clear secretions from airway. 4. Perform coordinated chest compressions.

Ans: 3,1,4,2

Question 23. The student nurse is watching the preceptor coach a client through the second stage of labor. During this stage, the nurse assesses the client for the urge to push and encourages the client to delay pushing until she feels the urge to. The student nurse recognizes this type of second-stage care as which? 1. Directed pushing 2. Spontaneous pushing 3. Nondirected pushing 4. Valsalva pushing

Ans:3 Option 1: Directed pushing is when the nurse coaches the client to hold her breath and push to the count of ten a few times with each contraction, starting as soon as the client is dilated to 10cm. Option 2: Spontaneous pushing refers to open-glottis involuntary pushing efforts. Option 3: Nondirected pushing refers to the process of waiting until Ferguson's reflex is felt to start the pushing process. Option 4: Closed-glottis or Valsalva pushing occurs with directed pushing.

Question 45. While caring for a client, which interventions would the nurse include in the nursing care plan to provide culturally competent care? Select all that apply. 1. Describe hospital protocols that will be followed during the delivery. 2. Provide teaching on non-pharmacological pain management options as they are preferred by women of the client's culture. 3. Identify who the woman prefers to care for her during labor and delivery. 4. Provide the client's preferred foods as appropriate or encourage the client's family to bring foods from home. 5. Determine who is the client's support person(s) and how they will participate in her care.

Ans: 3,4,5 Option 1: While it is important to explain protocols and procedures to the client, this is not providing care that is individualized to her needs. Option 2: Some cultures do prefer to avoid pain medication, but the nurse should not assume that to be true of every member of a cultural group. Option 3: This is a client-focused intervention. Male providers may be forbidden in some cultures or make the woman uncomfortable. Option 4: This is a client-focused intervention. Some clients prefer only warm foods for the mother or observe specific dietary restrictions. This provides an appropriate selection for the mother. Option 5: This is a client-focused intervention. Labor support is strongly connected to positive outcomes, and the nurse can identify who will be assisting the client.

Question 39. Following a vaginal exam on a client in labor, the nurse documents the client to be 8cm, 80%, +1. Which do these terms represent? 1. Cervical effacement, fetal station, cervical dilation 2. Cervical effacement, dilation, fetal station 3. Fetal station, cervical dilation, cervical effacement 4. Cervical dilation, effacement, fetal station

Ans: 4 Option 1: Cervical dilation is measured in cm, while effacement is measured in %, and fetal station in + or - numbers from 0. Option 2: Cervical dilation is measured in cm, while effacement is measured in %, and fetal station in + or - numbers from 0. Option 3: Cervical dilation is measured in cm, while effacement is measured in %, and fetal station in + or - numbers from 0. Option 4: Cervical dilation is measured in cm, while effacement is measured in %, and fetal station in + or - numbers from 0.

Question 20. Upon starting a shift in the labor and delivery unit, the nurse is assigned to care for a 15-year-old client in active labor. When entering the room to assess the client, the nurse finds a room full of visitors and notes the client appears uncomfortable. which is the appropriate nursing intervention at this time? 1. Insist that all visitors leave the room so that it can be a quiet labor environment. 2. Tell the client you will come back to check her blood pressure after everyone leaves. 3. Determine who the visitors are, so the nurse can focus her assessment questions towards the parents of the client. 4. Request that everyone step out during the assessment and ask the client whom she would like in the room for the birth.

Ans: 4 Option 1: The client should choose who she would like to have in the room for the labor and delivery process. Option 2: The client looks uncomfortable and needs to be examined. Coming back later would not be the best option. Option 3: The adolescent should be included in all decision-making. Option 4: The adolescent should be included in all decision-making. Requesting time to discuss her choices allows for adequate decision making.

Question 34. A client requests to keep the placenta following delivery. How would the nurse respond to this request? 1. "We do not allow that in this hospital. It is against all regulations." 2. "Can you tell me what you plan to do with the placenta? We only allow this if you plan to bury the placenta." 3. "Why would you want to take that home? It will begin to smell and can attract insects." 4. "I understand that this is very important to you, and I will see what I can do to honor this request."

Ans: 4 Option 1: There are generally exceptions to the regulations, although paperwork may be required. Option 2: This is not the best answer, as it only allows some requests to be accommodated. All cultural requests should have an effort made for accommodation. Option 3: This response is lacking in therapeutic communication techniques. Option 4: It is best to try to accommodate requests for cultural considerations.

Question 48. A client was recently admitted to the labor and delivery unit in active labor. The nurse performs Leopold's maneuvers during the assessment. During the third maneuver, the nurse notes a firm and fixed fetal part. Which position correlates with this assessment finding? 1. Occiput 2. Acromion 3. Sacrum 4. Transverse

Ans:1 Option 1: During Leopold's maneuvers, the fetal head will palpate as firm and fixed, correlating to an occiput presentation. Option 2: The acromion would not be fixed into the pelvis during palpation. Option 3: The sacrum would palpate as soft, as opposed to firm. Option 4: The transverse lie would correspond to the acromion presentation.

Question 46. Which nursing interventions would support a normal, physiologic birth? Select all that apply. 1. Waiting until 40 weeks gestation to induce labor 2. Assisting the mother to change positions frequently 3. Collaborating with a doula or other support person to manage discomfort 4. Encouraging the mother to lie on her back and place her feet in stirrups for delivery 5. Allowing the bag of waters to rupture spontaneously

Ans:1,2,3,5 Option 1: In absence of any complications, allowing the labor to start on its own is supportive of normal, physiologic birth. Option 2: The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including freedom of movement throughout labor. Option 3: The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including continuous support from family, friends, doulas, or nursing staff. Option 4: The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including spontaneous pushing in non-supine positions. Option 5: The World Health Organization and Lamaze International identified six birth practices that support and promote normal physiologic birth, including minimizing interventions.

Question 25. The nurse is caring for a client in the latent phase of labor who is requesting pain medication. which is the appropriate nursing response regarding the administration of pain medication for this client? 1. "I will call the provider and obtain an order for the medication." 2. "It is best to wait until active labor. I can show you some pain management techniques." 3. "The provider never gives pain medication this early in labor." 4. "It is way too soon for that. You have a lot of time in labor to go."

Ans:2 Option 1: Labor needs to be well established prior to calling for an order. Option 2: Always remember therapeutic communication techniques when talking to clients. Labor should be well established prior to administration of analgesia. Option 3: Labor needs to be well established prior to giving an analgesic. Option 4: Labor should be well established before pain medication is introduced.

Question 41. With regard to a pregnant woman's anxiety about her labor experience, which does the nurse recognize? 1. Anxiety may increase the perception of pain, but it does not affect the process of labor. 2. Women who have had a painful labor will have learned from the experience and have less anxiety the second time because of increased familiarity. 3. Severe anxiety can increase pain and stress, which renders uterine contractions less effective. 4. Continuous labor support decreases anxiety, but has no effect on pain perception or use of pain medication during labor.

Ans:3 Option 1: Psyche is one of the 5 Ps that affect labor. A woman's emotional state does indeed have an effect on labor outcomes. Option 2: A woman with a history of difficult or traumatic labor may be more fearful and anxious than a nulliparous woman. Option 3: High levels of stress and anxiety release epinephrine, which may lead to decreased uterine contractility and a longer active labor phase. Option 4: A recent Cochrane review concluded that continuous support during labor may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labor, a decrease in cesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar scare, and negative feelings about childbirth experiences.

Question 24. The nurse is assessing a low-risk pregnant client and documenting fetal heart tones every 5 minutes. which stage of labor is this client in, based on the frequency of assessments being performed? 1. Latent phase 2. Early phase 3. First stage 4. Second stage

Ans:4 Option 1: During the latent phase of labor, fetal heart tones only need to be documented every 30 minutes. Option 2: During the early phase of labor, fetal heart tones only need to be documented every 30 minutes. Option 3: During the first stage of labor, fetal heart tones are documented at various intervals, depending on the phase the client is in during this stage. Option 4: During the second stage of labor, fetal heart tones are documented every 5 to 15 minutes.

Question 22. The nurse receives a call from the partner of a client in labor. The partner asks when they should come to the hospital. During which part of labor would a pregnant client be told to come to the hospital? 1. Transition phase 2. Fourth stage 3. Second stage 4. Active phase

Ans:4 Option 1: The transition phase is the last part of the first stage of labor, and clients should already be at the hospital. Option 2: The fourth stage is the initial recovery period following the placenta delivery. Option 3: The second stage is the second stage of labor and is the pushing stage. Option 4: Women should report to the hospital during the active phase of labor.

Question 47. The nurse is preparing a group session for childbirth preparation. The topic will include signs of impending labor. The nurse will include which topics? Select all that apply. 1. Lightening 2. Decreased fetal movement 3. Nesting 4. Bloody show 5. Weight gain

Ans; 1,3,4 Option 1: For first-time pregnancies, approximately two weeks before labor, the baby will drop in to the pelvis. This is called lightening. Option 2: Decreased fetal movement at any time in pregnancy is considered abnormal. Option 3: Many women feel a burst of energy near the end of pregnancy, called nesting. Option 4: Bloody show is blood tinged or brown mucous discharge that occurs as the cervix begins to ripen. Option 5: It is more likely that women would lose weight as labor nears.

Question 44. The process of labor is multifactorial. The five primary factors include powers, passage, passenger, psyche, and: 1. Pressure 2. Patience 3. Position 4. Pelvis

Ans; 3 Option 1: Pressure on the cervix is exerted by uterine contractions pushing the presenting part downward. However, pressure falls under the "powers" category. Option 2: While some women labor longer than others, it is not a primary factor in the outcome of delivery. Option 3: Maternal position affects labor outcomes by promoting the anatomical and physiological adaptations that make vaginal delivery possible. Option 4: The shape and size of the maternal pelvis falls under the "passage" category.

Question 12. The nurse is caring for a client in the first stage labor. To assist the progression of labor, the nurse recommends: 1. Changing positions and sitting upright 2. Maintaining a side-lying position only 3. Receiving an epidural as early as possible so she can relax and rest 4. Limiting visitors at the beside to promote rest

Answer: 1 Option 1: Frequent position changes and upright positions facilitate fetal descent and decrease pain perception. Option 2: Side-lying positions are helpful to increase perfusion and lower BP, but do not facilitate dilation of the cervix and fetal descent. Option 3: Once she has received an epidural, a woman's freedom of movement is greatly diminished. Option 4: Continuous labor support has been shown to improve outcomes by decreasing pain medication usage and increasing satisfaction with the birth experience.

Following the delivery of a term newborn, the mother experiences a moderate urge to push and a gush of blood emerges from the vagina. The nurse recognizes this as: 1. Indicating the placenta is about to deliver 2. The formation of a vaginal hematoma 3. Perform a cervical exam 4. Signs of a postpartum hemorrhage

Answer: 1 Option 1: Once the placenta separates from the wall of the uterus, the uterus continues to contract until the placenta is expelled. This process typically takes 5 to 30 minutes post-delivery of the baby, and occurs spontaneously. Signs that signify the impending delivery of the placenta include upward rising of the uterus into a ball shape, lengthening of the umbilical cord at the introitus, and sudden gush of blood from the vagina Option 2: Hematomas are a collection of blood under the skin resulting from birth trauma. The mother may feel increased perineal pressure, but there is no outward bleeding. Option 3: The question did not provide any information regarding a second fetus. The mother would likely feel more than a moderate urge to push and there should not be a gushing of blood. Option 4: Postpartum hemorrhage is most likely to occur after delivery. Signs typically include a boggy uterus, heavy bleeding with possible golf ball size or larger clots, and alterations in vital signs. It does not include an urge to push.

Question 15. The nurse midwife performs Leopold's Maneuvers to determine fetal positioning in the womb. which can the midwife determine by palpating the woman's fundus? 1. If the fetus is breech or vertex 2. The location of the back and fetal small parts 3. The fetal presenting part 4. The location of the cephalic prominence

Answer: 1 Option 1: The first maneuver, palpating the fundus, can determine was occupies the fundus. If it is the head, the infant is breech. If it is the buttocks, the infant is vertex. Option 2: The second maneuver locates the fetal back. This is done by feeling down the sides of the abdomen, not the fundus. Option 3: The third maneuver determines the fetal presenting part by feeling near the maternal pelvis. Option 4: The fourth maneuver determines the location of the cephalic prominence. This maneuver is done by the maternal pelvis, not the fundus.

Question 18. The nurse initiates a fluid bolus prior to epidural administration. which is the purpose of this action? 1. To stabilize post-epidural blood pressure 2. To prevent hypovolemia following blood loss after delivery 3. To increase amniotic fluid volume and cushion the umbilical cord 4. To flush fentanyl metabolites from maternal circulation

Answer: 1 Option 1: The most common side effect from an epidural is hypotension. The nurse must give a fluid bolus to prevent hypotension and possible fetal compromise. Option 2: The question asks specifically about giving a bolus before an epidural. While maintaining hydration during labor is important, a prophylactic fluid bolus is not standard to prevent hypovolemia. Option 3: The question asks specifically about giving a bolus before an epidural. A fluid bolus would not acutely affect amniotic fluid volume. Also, cord compression is not the nurse's priority at this time. Option 4: The anesthesiologist doses epidural medication based on height and weight. In a healthy woman, the body will metabolize the drugs effectively, and additional fluids are not needed to "flush out" her system.

The nurse is caring for a client being augmented with oxytocin. What potential complications should the nurse observe the client for? Select all that apply. 1. Tachysystole 2. Late decelerations on the fetal monitor 3. Episodic accelerations 4. Uterine rupture 5. Maternal edema

Answer: 1,2,4,5 Option 1: The purpose of oxytocin is to cause uterine contractions. If not titrated correctly, tachysystole (more than 5 contractions in a 10-minute period) could occur. Option 2: Uterine contractions that are too long or too frequent can disrupt perfusion to the placenta, causing late decelerations in the fetal heart rate. Option 3: Accelerations are present in a well-oxygenated fetus. This often occur as a response to fetal movement and they are a normal sign. Option 4: Uterine contractions that occur too frequently or with too much force could cause uterine rupture. Special care must be taken with those at higher risk, such as multiparous women and those who have had previous cesareans. Option 5: Oxytocin has an antidiuretic effect. This can cause water retention and new onset or worsening edema in the mother.

Question 6. Following a precipitous labor, the obstetrician did not arrive to the hospital in time for the delivery. The nurse is monitoring for the delivery of the placenta. Which indications would result in the nurse asking the client to push to deliver the placenta? Select all that apply. 1. A sudden gush of blood from the vagina 2. Client starts to feel very nauseous 3. Umbilical cord lengthens at the vaginal introitus 4. Uterus rises upward in a ball shape 5. Blood pressure and pulse rate decrease

Answer: 1,3,4 Option 1: When the placenta separates from the wall of the uterus, there will be additional bleeding that results in a gush of blood from the vagina. Option 2: The client may feel nauseous following delivery, but it is unrelated to the placenta detachment. Option 3: When the placenta detaches, there will be additional length of the umbilical cord due to the downward movement of the placenta. Option 4: The uterus rises upward at the time of placental detachment. Option 5: The blood pressure and pulse rate may fluctuate following delivery. However, this is unrelated to the placenta detachment.

Question 14. The nurse is caring for a client using a labor doula. While collaborating for the client's care, which activity would not be delegated to the doula? 1. Assisting the woman to ambulate in the hall 2. Auscultating fetal heart tones while the woman uses the whirlpool 3. Applying heat and cold to the woman's lower back 4. Advocating for the woman's birth plan to be followed

Answer: 2 Option 1: Doulas may provide physical support of the client, such as ambulation and position changes. Option 2: Auscultating fetal heat tones is a clinical task that should be completed by hospital staff. The doula likely does not have the appropriate training, nor would she be able to chart the data. Option 3: Doulas assist with nonpharmacologic pain management techniques such as application of heat/cold, massage, breathing, etc. Option 4: Doulas provide emotional support for the woman. This can include advocating on her behalf and making her care wishes known.

Question 10. The nurse is rapidly determining the need for resuscitation immediately following delivery of a 36-week infant. The nurse must answer yes to which questions to determine that skin-to-skin contact is appropriate? Select all that apply. 1. How long was the mother in labor? 2. Is the infant a term gestation? 3. Does the newborn have good muscle tone? 4. Is the baby crying and breathing? 5. Were medications given during labor?

Answer: 2,3,4 Option 1: While the length of labor may impact baby, this question is not one of the rapid appraisal questions. Option 2: This question is a part of the rapid assessment. Option 3: This question is a part of the rapid assessment. Option 4: This question is a part of the rapid assessment. Option 5: While this question may be appropriate in further assessing an infant that is struggling, it is not a part of the rapid assessment.

Question 9. A new mother is refusing all medications for her newborn infant. The obstetrician has asked the nurse to explain the purpose of the Vitamin K injection to the parent. How would the nurse explain the need for this medication? 1. "This medication will help prevent infections in the eyes due to bacteria in the birth canal." 2. "All medications are required in our state, so you will not be able to refuse this medication." 3. "This medication is given because the infant does not yet have good bacteria in the gut to help with clotting." 4. "This medication is the first of several that will prevent viral liver disease."

Answer: 3 Option 1: This statement is true for the erythromycin eye ointment. Option 2: While newborn medications are common, they are not required. Option 3: Vitamin K is given to help with synthesis of clotting factors. Option 4: The hepatitis B vaccine helps to prevent a viral infection and is a series of three injections.

During the transition phase, the client states that she feels a strong urge to push. The nurse explains that which reflex triggers this urge? 1. Deep tendon reflex 2. Moro reflex 3. Naegele's reflex 4. Ferguson's reflex

Answer: 4 Option 1: Deep tendon reflexes assess the functionality of the nervous system. Option 2: Moro reflex is seen in newborn infants and is sometimes referred to as the startle reflex. Option 3: Naegele's rule is used to calculate due dates. Option 4: Ferguson's reflex is the reflex that triggers the urge to push.

Upon vaginal examination, the nurse notes that the infant's anterior fontanel is to the back left side of the maternal pelvis. How does the nurse chart this position? 1.ROA 2.LOA 3.ROP 4.LOP

Answers: 1 Option 1: The occiput is the landmark used for identifying fetal position. If the anterior fontanel is pointing to the back (posterior) left of the maternal pelvis, then the occiput is pointing toward the right, anterior maternal pelvis. Option 2: In this position, the occiput is toward the maternal left anterior pelvis. LOA would mean the anterior fontanel would be pointing right posterior. Option 3: In this position, the occiput is toward the maternal right posterior pelvis. ROP would mean the anterior fontanel would be pointing left anterior. Option 4: In this position, the occiput is toward the maternal left posterior pelvis. LOP would mean the anterior fontanel would be pointing right anterior.